Support Group for Black Women

This group is to explore the experiences and identity of being a Black woman in various spaces. You may be feeling stressed or anxious and find that friends, family, or close acquaintances just don’t understand. This group is for women that need support but are not in traumatic situations or currently in crisis. You may be seeking support for daily stressors from your life, relationships, society, or work. It's a good fit if you are overwhelmed with the impacts school, parenting, peers and romantic relationships or the intense racial climate. This group is not a good fit if you are in a state of crisis, have been diagnosed with moderate to severe depression, have a mood disorder or personality disorder diagnosis, or if you have an ongoing, untreated mental challenge or illness that is not being treated by an individual licensed professional.

If you still have questions please contact me at 770-294-4006 or want more information about the group please visit the group page:Empowered Circle Support Group for Black Women

NOTE: This is a new group that is actively being filled. Once the minimum number is reached, all accepted participants who responded will be emailed with further information and your client portal will be set up.

Name*

First NameLast Name

E-mail*

example@example.com

Phone Number

I understand that this group is for black women. (Please stop here if you are not a black women and reach out to see if we have another group that can accommodate you.)*

YesNo

Have you ever participated in a support group before? If yes, what was that experience like? Was there anything in your previous you were concerned about?

Do you feel comfortable sharing and listening to others in a group setting? This is important as you will be a part of an online support group.*

YesNo

Are you currently seeing a therapist or counselor?*

YesNo

Have you experienced any recent (within the last 6-18 months) mental health crises (e.g., hospitalizations, suicidal thoughts) that might require more focused individual care?*

YesNo

Have you been diagnosed with severe depression, mood disorder, PTSD, or a personality disorder that requires ongoing, individual treatment?*

YesNo

If yes, are you currently in treatment with a therapist or psychiatrist?*

YesNo

Are your symptoms currently managed enough to participate in a group focused on skill-building and community support (not trauma processing*

YesNo

I understand this group is offered weekly and online. I understand groups fees are $95/per session but are paid monthly. I am willing to make the required 8 week minimum commitment to attend the group.*

Yes, I understandNo, I can't make the minimun commitment

Are you able to commit to maintaining confidentiality and respecting the boundaries of others in the group? (This is critical in maintaining trust, connection, and rapport in the group.)*

YesNo

The group meets has two meeting times Monday. Pick which one is best for you. If none of those times work please add a time that does.

I understand that this group is a support group that is not covered by insurance and I will have to pay out of pocket. I understand I can use my HSA/FSA funds and any debit or credit card.*

YesNo

Once you are enrolled in the group it is important to watch out for your welcome email and choose what group time is best for you. Once the group starts please be sure you have access to a private and quiet space with a stable internet connection for online sessions? (You can access the virtual group where it is convenient for you as long as you have privacy, not in a moving vehicle, and can help maintain your confidentiality and others in the group.) I understand that I am signing up for this group but I am not in the group until I have set up my client portal and have completed all my paperwork

This group is actively being filled and as soon as we have 4 women sign up we will get started.

I can't wait to meet you!!

EMPOWERED TRANSITIONS COUNSELING

www.empowertransitions.com

770-294-4006

Date of Signature*

Signature: (By signing this form I understand that I am being considered for group enrollment and that once accepted I still need to complete all paperwork to gain access to the group. Please look out for all emails once your client portal is set up)*

Please leave any questions, suggestions, or concerns you can leave them here or text me at 770-294-4006. For more information about the group, please check out the group page.

Support group for Black Women